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 Table of Contents    
EDITORIAL COMMENTARY  
Year : 2016  |  Volume : 58  |  Issue : 4  |  Page : 363-365
Mental Health Care Bill-2016: An illusory boon; on close reading it is mostlybane


Department of Psychiatry, Jubilee Mission Medical College and Research Centre, Trissur, Kerala, India

Click here for correspondence address and email

Date of Web Publication27-Dec-2016
 

How to cite this article:
Antony JT. Mental Health Care Bill-2016: An illusory boon; on close reading it is mostlybane. Indian J Psychiatry 2016;58:363-5

How to cite this URL:
Antony JT. Mental Health Care Bill-2016: An illusory boon; on close reading it is mostlybane. Indian J Psychiatry [serial online] 2016 [cited 2019 Aug 24];58:363-5. Available from: http://www.indianjpsychiatry.org/text.asp?2016/58/4/363/196721


The recent editorial, “Mental Health Care Bill (MHCB): a Boon or Bane,” states that the “Bill”[1] is progressive and rights-based in nature.[2] May be, a wide definition for mental illness, along with the enumeration of many patients' - rights has kindled optimism in its authors. But, generous offers by a Law are unlikely to persuade many to admit their mental illness. The reason: the devastating effects that stigma has in our society.

The editorial [2] has rightly observed that “the Bill tries to be over inclusive in its approach, stretching beyond the legislative limits and despite noble intentions behind it, would be a challenge to stakeholders whether the contents of the Bill are legislation, program, policy or even a treatment guideline.”

The main defect of this draft law is this style of packing it with many vague, unenforceable “policies and treatment guidelines,” much in the fashion of some propaganda material. Any practisimg psychiatrist in India would expects the editorial to comment on this lack of focus and precision, a little more forcefully.

However, the editorial has not only failed to do this; it is as though its learned authors want the Bill to go further, with its propaganda-style, in more areas! They state in paragraph two of the editorial that “priorities of mental health care have to be shifted from psychotic disorders to common mental disorders and from mental hospitals to primary mental health centers.”[2] The reason given is an increase in “invisible” mental problems! Indeed similar views on these matters have been expressed by some authors earlier, as well.[3],[4]

But, this approach, of wanting to give an emphasis to “community” in relation to “hospital” or giving attention to “invisible problems”, in a new law is quite unfortunate. These may indeed be good ideas, which could possibly be taken up, when a new mental health “policy” or “programme” is formulated. A law must always be clear, unequivocal and focussed.

It is rather cruel to have a view that psychotic patients in this country are getting some “priority treatment”! And, as for mental hospitals, where is this priority when centuries old dilapidated buildings are still waiting to be pulled down and re-built?

The editorial also says that “places like juvenile homes, destitutes or beggars' homes and religious places, where mental patients are housed need not have license.”[2] This statement in an editorial of the official publication of the Indian Psychiatric Society is unfortunate. One expects the Journal to speak for the sake of the mentally ill, rather than for those who run mental health establishments.

Maybe, they are making this suggestion, equating various “care-homes” with general hospital psychiatry units. But, sparing general hospitals, from the hassles of a license is a different matter; a bystander would be there to secure the rights of a patient, and this has been pointed out, earlier.[5],[6] But allowing people to run institutions for chronic psychotics, without supervision is not acceptable. The danger of this approach has been elaborately dealt with, recently.[7]

Not only license, such places must also have close, on-going supervision. It is painful when senior psychiatrists are mocking at the need for surveillance of all kinds of care homes, by saying it will bring-in a “Licence Raj.”[2] How could Indian psychiatrists forget that huge man-made national shame called “Erwadi tragedy?”[8],[9],[10]

The important thing that should worry practicing psychiatrists, with regards to MHCB-2016 is that it would repeal the existing law, the Mental Health Act-1987.[11] And with such repealing, legal provisions, for tackling many situations that a psychiatrist faces in his day-to-day practice, will become just impossible.

A glaring example is the issue of compulsory admission of acute psychotics. In the present law, it is dealt with in section 19 in a very simple, straight manner. Another area where the draft law has deficiencies is in ensuring that chronic psychotics would get a decent care. When the present system of having “Board of Visitors” to oversee the functioning of every institution gets scrapped by MHCB-2016, such patients will be completely at the mercy of those who run “care homes.”

Most of these serious oversights have happened, owing to the un-scientific manner in which mental illness is to be determined, for different purposes, as per provisions of MHCB-2016. After giving an all-inclusive definition for mental illness in section 3, the Bill goes on to section 4 and defines a patient's “capability of making one's own treatment decisions.” Here, all that is needed is an ability to handle information: “Understands information,” “retains information” and “weighs the information and communicates decision, based on it.”

Further, in section 98, where patients with “high support needs,” or those who needs compulsory treatment are to be identified, three extremely rigorous criteria are laid down, all in the sphere of behavior. These are, “threat of bodily harm to self,” “threat of harm towards other” and “manifest inability to care for self, which may place him at risk of harm to oneself.” At least one of these has to be there, to be determined as having “high support needs!”

Both section 4 and section 98 of the Bill makes compulsory admission of those who need it, virtually impossible. Section 4 is quite liberal while conferring patients a “capacity to make treatment decisions.” Even a person with grave mental illness shall be deemed fit to make such decisions, if he can “deal with information;” his “capacity to make treatment decisions” is protected by law!

And then section 98, which is supposed to enable the profession or the “establishment” to administer compulsory treatment, provisions are extremely stringent. Forced treatment cannot be done unless a threat of “causing physical harm” is there!

Further, as the draft law has provisions such as “advance directive” and “nominated representative,” in the name of empowerment of patients, a family's attempts to get a dangerously ill psychotic patient would be defeated, even more badly.

The question is why such a special right is conferred to “mental patients,” while those with other illnesses are not given similar rights? Incidently this is against the spirit of our National Mental Health Programme, which requires that mentally ill are to be treated, exactly like other patients.

While most patients, because of sociocultural reasons, are unlikely to use provisions like 'advance directive', ever in their lifetime, some patients, especially victims of “paranoid psychosis” would be very enthusiastic about misusing such provisions. Imagine the situation in a family, where a paranoid schizophrenic succeeds in defeating the earnest attempts of his dear ones, to get him treated! He would go on in his terribly psychotic ways and may even commit a dastardly act, based on a closely guarded delusion!

Many serious errors of this type have crept into MHCB-2016, mainly because while drafting this, authors have failed to make use of the expertise of professionals, with experience in clinical psychiatry. While in standard clinical practice, a close study of dysfunctions of thought and emotion by a trained psychiatrist is mandatory for making a diagnosis, in the Bill under discussion, this is not a requirement to determine the nature and severity of mental illnesses!

Both sections 4 and 98 ignore this need for proper evaluation by psychiatrists, but at the same time has given certain criteria that are un-scientific and for that reason, not acceptable. Further, section 98 (1a) of the Bill, states that “persons with mental illness with high support needs is to be determined by one psychiatrist and one “mental health professional” or a “registered medical practitioner.”

The authors of the draft law seem to believe that many non-psychiatrists also could do a clinical evaluation and diagnose psychiatric disorders! This poor opinion about the professional skill or rather a distrust of psychiatrists is the common thread, in this entire draft-law.

It peaks up in section 104 (chapter XII), which is on “prohibited procedures.” Therein, electroconvulsive therapy (ECT) without muscle-relaxant, ECT of minors and “chaining” of patients are all grouped together and prohibited! Obviously authors of the Bill think that ECT without muscle-relaxant is some kind of a punishment that psychiatrists inflict on the mentally ill!

It is insensitive and rude to denounce a treatment modality that has saved innumerable lives, since over 75 years! Even today for severely ill “lethal catatonics” ECT is life-saving; and on rare occasions, it is given without muscle relaxants and even without anesthesia, as measures to minimize the risk to a patient.

This being the case, why a law wants to step in and tell the profession about the manner in which this treatment is to be administered? Has this sort of an intrusion into the autonomy of a section of medical practitioners has ever been done? The fundamental question that agitates all self-respecting psychiatrists, in the country is why a law is being enacted to make a mockery of their autonomy, to practice their calling?

This distrust of the highest law-making body of the nation amounts to telling the profession that “your present functioning based on teachings, traditions and textbooks and also, subject to controls by various statutory and other regulatory bodies is not acceptable to us!” And what good for the mentally ill is being sought to be achieved by the Honourable Parliament, by destroying the morale of the main professional group who looks after them?

The editorial,[2] which has failed to comment on the failure of the Bill to address issues pertaining to the proper care of both acute and chronic psychotics, goes on to state that any shortcomings in the draft Act, can be cured when rules are framed! This statement is probably intended to console psychiatrists in India. But it is misleading, as it is a settled position in law, that Rules can be framed only within the boundaries set by provisions of an Act and not to expand its scope or reach.

Chapter XI of the Bill is about the legal apparatus to oversee the entire field of mental health care. It mainly has two institutions, the “Mental Health Review Commission,” at the national level and a “Mental Health Review Board,” for each revenue district, all over the country.

A District Mental Health Review Board will have six members, of which only one would be a psychiatrist. And the main duty of such a board (as per se ction 85) is redressal of the grievance of persons with mental illness, or their representatives.

Here, a lay body is to assess the treatment and care that psychotic patients receive, and that too based on very rigid and unscientific criteria laid down in sections 4 and 98. And then, the same lay body would pass judgment, on the manner in which such patients were managed by psychiatrists! To put it mildly, this whole approach would be disastrous.

The effectiveness of having a Mental Health Review Commission, at the national level, to regulate the entire field of mental health care, is questionable. How a Commission located in Mumbai, will be able to reach out to thousands of “care homes” spread-out all over our vast country and secure a safe and dignified care of innumerable “dumb” chronic psychotics?

Here, lawmakers have to dispassionately examine whether having a “Board of Visitors” with its local commitment or a top-heavy regulatory body in Mumbai, which cannot be even accessed by victims, is to be preferred.

The present system of having 'Mental Health Authorities' at the national and state level, along with 'Board of Visitors' for every establishment where mentally ill are housed is quite adequate to take care of things, quite well. All that is needed is a political will to implement it, effectively. And there is always the writ jurisdiction of the Honorable High Courts to correct and remedy, if anything goes wrong.

The authors of MHCB-2016 seem to forget that their important duty is to protect the interests of two especially vulnerable groups, namely, acute and chronic psychotics. If they think that their only job is to make a “welfare-law,” to be in line with United Nations Convention on the Rights of Persons with Disabilities, it will be a major let-down of victims of major mental illness and their families. And when the present Mental Health Act-1987 is repealed, without provisions in the new law to protect the interests of major psychotics, the damage done to the entire field of mental health care would be terrible.

 
   References Top

1.
Mental Health Care Bill. Available from: http://www.prsindia.org/media. [Last accessed on 2016 Nov 12].  Back to cited text no. 1
    
2.
Rao GP, Math SB, Raju MS, Saha G, Jagiwala M, Sagar R, et al. Mental health care bill, 2016: A boon or bane? Indian J Psychiatry 2016;58:244-9.  Back to cited text no. 2
  Medknow Journal  
3.
Math SB, Chandrashekar CR, Bhugra D. Psychiatric epidemiology in India. Indian J Med Res 2007;126:183-92.  Back to cited text no. 3
[PUBMED]  Medknow Journal  
4.
Math SB, Murthy P, Chandrashekar CR. Mental health act (1987): Need for a paradigm shift from custodial to community care. Indian J Med Res 2011;133:246-9.  Back to cited text no. 4
[PUBMED]  Medknow Journal  
5.
Antony JT. A decade with the mental health act, 1987. Indian J Psychiatry 2000;42:347-55.  Back to cited text no. 5
[PUBMED]  Medknow Journal  
6.
Antony JT. The mental health care bill 2013: A disaster in the offing? Indian J Psychiatry 2014;56:3-7.  Back to cited text no. 6
[PUBMED]  Medknow Journal  
7.
Antony JT. Mental health legislation: A journey back to “madhouses era?” Indian J Psychiatry 2016;58:114-8.  Back to cited text no. 7
    
8.
Trivedi JK. Implication of Erwadi tragedy on mental health care system in India. Indian J Psychiatry 2001;43:293-4.  Back to cited text no. 8
[PUBMED]  Medknow Journal  
9.
Murthy SR. Lessons from the Erwadi tragedy for mental health care in India. Indian J Psychiatry 2001;43:362-6.  Back to cited text no. 9
[PUBMED]  Medknow Journal  
10.
Antony JT. Let us learn the right lessons from Erwadi. Indian J Psychiatry 2002;44:186-9.  Back to cited text no. 10
[PUBMED]  Medknow Journal  
11.
Mental Health Act 1987; With Short Notes and with Central MHA Rules 1990. Delhi Law House; 2003.  Back to cited text no. 11
    

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Correspondence Address:
James T Antony
Department of Psychiatry, Jubilee Mission Medical College and Research Centre, Trissur - 680 005, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0019-5545.196721

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